MEDICARE: EYE SPECIALISTS LASER & SURGERY CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0132X	Ophthalmologic Surgery Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F1554	OTHER	FL	MEDICARE
2	P00936589	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1508182577	OTHER	FL	UNITED HEALTHCARE
5	6CG	OTHER	FL	BC/BS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508182577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SPECIALISTS LASER & SURGERY CENTER INC

Provider Business Mailing Address
First Line	:	12453 S CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3828
Country	:	US
Telephone Number	:	239-939-1444
Fax Number	:	239-275-3332

Provider Business Practice Location Address
First Line	:	12453 S CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3828
Country	:	US
Telephone Number	:	239-939-1444
Fax Number	:	239-275-3332

Authorized Official
Title or Position	:	MEDICAL DOCTOR/PRESIDENT
Name	:	MARK S GOROVOY
Credential	:	M.D.
Telephone Number	:	239-939-1444

Provider Enumeration Date	:	04/15/2010
Last Update Date	:	08/26/2011

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Directions to “EYE SPECIALISTS LASER & SURGERY CENTER INC ” Practice Location

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